Rapid referral guidance toolkit for suspected cancer

Macmillan Cancer Support


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Introduction

The rapid referral guidance toolkit has been produced by Macmillan Cancer Support. It contains the NICE referral guidelines for suspected cancer (2015 update) with accompanying notes from Macmillan GPs and GP advisers (GPAs). It’s been produced by GPs for GPs with the aim of providing support, guidance and practical referral recommendations

Macmillan’s Rapid Referral Guidelines are based on NICE guidance whose remit covers England and Wales. This toolkit supports all of the recommendations in the NICE guideline on suspected cancer: recognition and referral apart from those relating to specific childhood cancers. For more information on this endorsement, please see the implementation section of the NICE website. GPs located in Scotland can access the Scottish Referral Guidelines for suspected cancer online

Glossary

These descriptions are consistent with and taken from the 2015 NICE guidance for suspected cancer

  • Children: From birth to 15 years
  • Direct access: When a test is performed and primary care retain clinical responsibility throughout, including acting on the result
  • Immediate: An acute admission or referral occurring within a few hours, or even more quickly if necessary
  • Suspected cancer pathway referral: The patient is seen within the national target for cancer referrals (2 weeks at the time of publication of the NICE guidance)
  • Young people: Aged 16–24 years of age

Key

  • Non-urgent: The timescale generally used for a referral or investigation that is not considered very urgent or urgent
  • Urgent: To happen/be performed within 2 weeks
  • Very urgent: To happen within 48 hours

Cancer types

Head and neck

Skin

Urological

Lung

Brain and CNS

Upper gastrointestinal

Bone and sarcoma

Breast

Haematological

Gynaecological

Lower gastrointestinal

Patient support, safety netting and diagnostic access guidance

Head and neck

Laryngeal cancer

Urgent referral

  • Consider urgent referral (appointment within two weeks) in patients:
    • aged 45 and over with either:
      • persistent unexplained hoarseness
      or
      • an unexplained lump in the neck

Oral cancer

Urgent referral:

  • Consider urgent referral (appointment within two weeks) for patients with:
    • an unexplained ulceration in the oral cavity lasting for more than 3 weeks
    or
    • a persistent and unexplained lump in the neck
  • Consider urgent referral (appointment within two weeks) for assessment by a dentist in patients with either:
    • an unexplained lump on the lip or in the oral cavity
    or
    • a red or red and white patch in the oral cavity consistent with erythroplakia or erythroleukoplakia
  • A dentist should consider urgent referral (appointment within two weeks) for patients with either of the following, which have been assessed by a dental surgeon and concluded to be consistent with oral cancer:
    • a lump on the lip or the oral cavity
    or
    • a red or red and white patch in the oral cavity consistent with erythroplakia or erythroleukoplakia

Thyroid cancer

Urgent referral:

  • Consider urgent referral (appointment within two weeks) in patients with:
    • an unexplained thyroid lump

Skin

Malignant melanoma

Urgent referral

  • Urgently refer (appointment within two weeks) if:
    • the patient presents with a suspicious pigmented skin lesion that has a weighted 7-point checklist score of 3 or more
    or
    • dermoscopy suggests malignant melanoma of the skin

Consider urgent referral (appointment within 2 weeks) for melanoma in patients with a pigmented or non-pigmented skin lesion that suggests nodular melanoma  

 Accompanying notes:

  • The 7-point weighted checklist: Major features (scoring 2 points each)
    • change in size
    • irregular shape
    • irregular colour
  • Minor features (scoring 1 point each)
    • largest diameter of 7 mm or more
    • inflammation
    • oozing
    • change in sensation

Squamous cell carcinoma

Urgent referral:

  • Consider urgently referring (appointment within two weeks) if patient has a skin lesion that raises the suspicion of squamous cell carcinoma

 Accompanying notes:

  • Squamous cell carcinomas are usually raised lesions, a number of typical features have been described: often ulcerated keratinised or crusting lesions and growing typically on the head and neck or back of hand. They occur commonly and are higher risk in anyone who is immuno-compromised or had a previous organ transplant. Refer all new skin lesions in this group urgently

Basal cell carcinoma

Urgent referral:

  • Only consider urgent referral (appointment within two weeks) for patients with:
    • a skin lesion that raises the suspicion of a basal cell carcinoma if there is concern that a delay may have an unfavourable impact, because of factors such as lesion site or size

Non-urgent referral:

  • Consider routine referral for patients with:
    • a skin lesion that raises the suspicion of a basal cell carcinoma

 Accompanying notes:

  • Features suggestive of a basal cell carcinoma include:
    • an ulcer with raised, rolled edge,
    • prominent fine blood vessels around the lesion,
    • nodules, often waxy or pearly in appearance
  • Suspected basal cell carcinomas should only be excised in primary care in accordance with the NICE guidance on Improving outcomes for people with skin tumours including melanoma (May 2010)
  • Specific sites of concern are sun-exposed areas such as the scalp, face, hands and arms, particularly in fair-haired patients

Urological

Prostate cancer

Urgent referral

  • Urgently refer men (appointment within two weeks) if either:
    • their prostate feels malignant on digital rectal examination (DRE)
    • or
    • their prostate specific antigen (PSA) levels are above the age-specific reference range

Non-urgent investigation:

  • Consider a PSA test and DRE in men with any of the following:
    • any lower urinary tract symptoms, such as nocturia, urinary frequency, hesitancy, urgency or retention
    • erectile dysfunction
    • visible haematuria

 Accompanying notes: 

  • Prostate-specific antigen ranges:
    • 40–49 years 0–2.5ng/l
    • 50–59 years 0–3.5ng/l
    • 60–69 years 0–4.5ng/l
    • 70–79 years 0–6.5ng/l
  • Consider alternative contributing factors that may influence an individual’s PSA ranges

Bladder cancer

Urgent referral:

  • Urgently refer patients (appointment within two weeks) if they are:
    • aged 45 and over with either:
      • unexplained visible haematuria without urinary tract infection
      • or
      • visible haematuria that persists or recurs after successful treatment of urinary tract infection.
    • Aged 60 and over with unexplained non-visible haematuria and either:
      • dysuria
      • or
      • a raised white cell count on a blood test

Non-urgent referral:

  • Consider referral in patients aged 60 and over with recurrent or persistent urinary tract infection that is unexplained

Renal cancer

Urgent referral:

  • Urgently refer patients (appointment within two weeks) if they are:
    • aged 45 years and over with either:
      • unexplained visible haematuria without urinary tract infection
      • visible haematuria that persists or recurs after successful treatment of urinary tract infection

Testicular cancer

Urgent referral:

  • Consider urgent referral (appointment within two weeks) in men with any of the following changes in the testis:
    • non-painful enlargement
    • change in shape
    • change in texture

Direct access ultrasound:

  • Consider a direct access ultrasound scan in men with unexplained or persistent testicular symptoms

Penile cancer

Urgent referral:

  • Consider urgent referral (appointment within two weeks) in men with any of the following, after exclusion of sexually transmitted infection as a cause or after treatment for a sexually transmitted infection has been completed:
    • a penile mass
    • an ulcerated lesion
    • unexplained or persistent symptoms affecting the foreskin or glans

Lung

Lung and pleural cancers

Urgent referral:

  • Urgently refer for lung cancer or mesothelioma (appointment within two weeks) in patients with:
    • chest X-ray findings that suggest lung cancer or mesothelioma
    • or
    • patients aged 40 and over with unexplained haemoptysis

Urgent investigations:

  • Consider an urgent chest X-ray (to be performed within two weeks) for lung cancer or mesothelioma in patients aged 40 and over with any of the following:
    • persistent or recurrent chest infection
    • finger clubbing
    • supraclavicular lymphadenopathy or persistent cervical lymphadenopathy
    • chest signs consistent with lung cancer or pleural disease
    • thrombocytosis

Urgent investigation:

  • Offer an urgent chest X-ray (to be performed within two weeks) to assess for lung cancer or mesothelioma in people:
    • aged 40 and over if they have never smoked with 2 or more of the following unexplained signs or symptoms
    • or
    • aged 40 and over and have previously smoked with 1 or more of the following unexplained signs or symptoms
    • or
    • any age if they have ever been exposed to asbestos and have 1 or more of the following:
      • cough
      • fatigue
      • shortness of breath
      • chest pain
      • weight loss
      • appetite loss

 Accompanying notes:

  • In symptomatic patients, the majority of chest X-rays will be abnormal, but a normal chest X-ray does not exclude diagnosis of lung cancer. This was shown in the 2006 BJGP study of normal and abnormal chest x-rays in lung cancer patients, 23% of lung cancer patients had a negative X-ray

Brain and CNS

Brain and CNS cancer

Very urgent referral:

  • Consider very urgent referral (appointment within 48 hours) in:
    • children and young people with newly abnormal central neurological or cerebellar function

Urgent direct access:

  • Consider urgent direct access MRI brain scan (appointment within 2 weeks) in:
    • adults with progressive, sub-acute loss of central neurological function

 Accompanying notes:

 A ‘normal’ scan
  • A normal investigation does not preclude the need for ongoing follow up, monitoring and further investigation. Furthermore, a seemingly ‘normal’ MRI scan may provide false reassurance in patients who have neurological pathology that MRI scanning is unable to detect.
  • Approximately 10% of patients may be unsuitable for, or unable to tolerate an MRI brain scan, e.g. patients with pacemakers in-situ or those with severe claustrophobia. In these patients a CT scan may be more appropriate, taking potential radiation exposure in to consideration
 Incidental findings
  • A small percentage of MRI scans may yield abnormalities in otherwise healthy individuals. This may impact on these patients in a number of ways including further investigation and the potential impact on health insurance premiums. As incidental findings are not an infrequent result of MRI scanning, patients should have prior counselling and information to make them aware of the potential for such findings as a consequence of their investigation
  • No definition of ‘progressive sub-acute loss of central neurological function’ has been provided for this update, but the 2005 NICE guidance for suspected cancer includes signs or symptoms that may cause concern, including: progressive neurological deficit, new-onset seizures, headaches, mental changes, cranial nerve palsy
  • Headaches of recent onset accompanied by features suggestive of raised intracranial pressure, e.g. vomiting, drowsiness, posture-related headache, pulse-synchronous tinnitus, or other focal or non-focal neurological symptoms, such as blackout or change in personality or memory
  • Consider urgent referral in patients with rapid progression of: sub-acute focal neurological deficit; unexplained cognitive impairment, behavioural disturbance or slowness, or a combination of these; personality changes confirmed by a witness and for which there is no reasonable explanation even in the absence of the other symptoms or signs of a brain tumour

Upper gastrointestinal

Oesophageal and gastric cancer

O=oesophageal; G=gastric:

Urgent referral for endoscopy within two weeks:

  • Urgently refer patients presenting with:
    • dysphagia (at any age) (OG)
    • or
    • aged 55 and over with weight loss
    • and
      • upper abdominal pain
      • or
      • reflux
      • or
      • dyspepsia (OG)

Consider urgent referral (appointment within two weeks) for patients with an upper abdominal mass consistent with stomach cancer (G)

Non-urgent direct access endoscopy:

  • Consider non-urgent direct access endoscopy for patients presenting with:
    • haematemesis (at any age) (OG)
    • or
    • aged 55 and over with:
      • treatment resistant dyspepsia (OG)
      • or
      • upper abdominal pain and low haemoglobin (OG)
      • or
      • raised platelet count with any of the following:
        • nausea
        • vomiting
        • reflux
        • weight loss
        • dyspepsia
        • upper abdominal pain (OG)
        or
      • nausea or vomiting with any of the following:
        • weight loss
        • reflux
        • dyspepsia
        • upper abdominal pain (OG)

Pancreatic cancer

Urgent referral:

  • Urgently refer patients (appointment within two weeks) if aged 40 and over with jaundice

Urgent direct access CT scan or an urgent ultrasound scan if CT scan is not available:

  • Consider urgent direct access CT scan (within two weeks) or ultrasound scan if CT scan is not available for patients:
    • aged 60 and over, displaying weight loss and any of the following:
      • diarrhoea
      • back pain
      • abdominal pain
      • nausea/vomiting
      • constipation
      • new-onset diabetes

Gall bladder

Urgent direct access

  • Consider an urgent direct access ultrasound scan (within two weeks) to assess for gall bladder cancer in people with an upper abdominal mass consistent with an enlarged gall bladder

Liver cancer

Urgent direct access

  • Consider an urgent direct access ultrasound scan (within two weeks) to assess for liver cancer in people with an upper abdominal mass consistent with an enlarged liver

 Accompanying notes:

  • Consider that 10% of pancreatic cancers are missed by abdomen ultrasounds, whilst tumours smaller than 3 cm will not be visible using an ultrasound. CT scans have the advantage of staging at the same time

Bone and sarcoma

Bone sarcoma

Very urgent direct access:

  • Consider a very urgent direct access X-ray (appointment within 48 hours) in any child or young person with unexplained:
    • bone swelling
    • or
    • bone pain

Very urgent referral:

  • Consider very urgent referral in children and young people (appointment within 48 hours) with:
    • an X-ray that suggests the possibility of bone sarcoma

Urgent referral:

  • Consider urgent referral (appointment within two weeks) in adults with:
    • an X-ray that suggests the possibility of bone sarcoma

Soft tissue sarcoma

Very urgent direct access:

  • Consider very urgent direct access ultrasound scan (performed within 48 hours) for children and young people with:
    • an unexplained lump that is increasing in size

Urgent direct access:

  • Consider urgent direct access ultrasound scan (performed within two weeks) in adults with:
    • an unexplained lump that is increasing in size

Very urgent referral:

  • Consider very urgent referral (within 48 hours) in children or young people with:
    • ultrasound scan findings that are suggestive of soft-tissue sarcoma
    • or
    • ultrasound scan findings that are uncertain and clinical concern persists

Urgent referral:

  • Consider urgent referral (within two weeks) in adults with:
    • ultrasound scan findings that are suggestive of soft-tissue sarcoma
    • or
    • ultrasound scan findings that are uncertain and clinical concern persists

Breast

Breast cancer

Urgent referral:

  • Urgently refer patients (appointment within two weeks) if they are male or female:
    • aged 30 and over with an unexplained breast lump (with or without pain)
    • or
    • aged 50 and over with any unilateral nipple changes of concern including discharge or retraction
  • Consider urgent referral (appointment within two weeks) if:
    • there are skin changes suggestive of breast cancer
    • or
    • they are aged 30 and over with an unexplained lump in the axilla

Non-urgent referral:

  • Consider non-urgent referral in patients under the age of 30 with an unexplained breast lump (with or without pain)

Haematological

Leukaemia

Very urgent investigation:

  • Refer children and young people for immediate specialist assessment for leukaemia if they have:
    • unexplained petechiae
    • or
    • hepatosplenomegaly
  • Offer a very urgent full blood count (within 48 hours) in children and young people with any of the following unexplained signs or symptoms:
    • pallor
    • persistent fatigue
    • fever
    • persistent infection
    • generalised lymphadenopathy
    • persistent or unexplained bone pain
    • bruising
    • bleeding
  • Consider a very urgent full blood count (within 48 hours) in adults with any of the following unexplained signs or symptoms:
    • pallor
    • persistent fatigue
    • fever
    • persistent or recurrent infection
    • generalised lymphadenopathy
    • bruising
    • bleeding
    • petechiae
    • hepatosplenomegaly

 Accompanying notes:

  • Refer adults, children and young people with a blood count or blood film reported as acute leukaemia immediately

Myeloma


Urgent investigation:

  • Offer a full blood count, blood tests for calcium and plasma viscosity or erythrocyte sedimentation rate (ESR) to patients aged:
    • 60 and over with:
      • persistent bone pain (particularly back pain)
      • or
      • unexplained fracture
  • Offer a very urgent protein electrophoresis and a Bence-Jones protein urine test (within 48 hours) to patients aged:
    • 60 and over with:
      • hypercalcaemia or leucopenia
      • and
      • a presentation that is consistent with possible myeloma
  • Consider a very urgent protein electrophoresis and Bence-Jones protein urine test (within 48 hours) if:
    • raised plasma viscosity or ESR at levels consistent with possible myeloma
    • and
    • presentation consistent with possible myeloma

Urgent referral:

  • Urgently refer (appointment within two weeks) if the results of protein electrophoresis or Bence-Jones protein urine test suggest myeloma

Lymphoma

Immediate specialist assessment:

  • Consider very urgent referral (appointment within 48 hours) in children and young people with:
    • unexplained lymphadenopathy
    • or
    • splenomegaly
  • Take into account associated symptoms, particularly:
    • fever
    • night sweats
    • shortness of breath
    • pruritus
    • weight loss

Urgent referral:

  • Consider urgent referral (appointment within two weeks) in adults presenting with:
    • unexplained lymphadenopathy
    • or
    • splenomegaly
  • Take into account associated symptoms, particularly:
    • fever
    • night sweats
    • shortness of breath
    • pruritus
    • weight loss
    • alcohol-induced lymph node pain

Gynaecological

Ovarian cancer

Urgent referral:

  • Urgently refer (appointment within two weeks) if physical examination identifies any of the following:
    • ascites
    • pelvic or abdominal mass (which is not obviously uterine fibroids)

Urgent investigation:

  • Arrange CA125 and/or ultrasound tests in women (especially if 50 or over) with any of the following on a persistent or frequent basis—particularly more than 12 times per month:
    • persistent abdominal distension (bloating)
    • early satiety and/or loss of appetite
    • pelvic or abdominal pain
    • increased urinary urgency and/or frequency
    • new onset symptoms suggestive of IBS (as IBS rarely presents for the first time in women of this age)
  • Consider CA125 and/or ultrasound tests if a woman reports any of the following:
    • unexplained weight loss
    • fatigue
    • changes in bowel habit (though colorectal cancer is a more common malignant cause)

Referral pathway for suspected ovarian cancer

    Referral pathway for suspected ovarian cancer

Endometrial cancer

Urgent referral:

  • Urgently refer women (appointment within two weeks) if they are:
    • aged 55 and over with:
      • post-menopausal bleeding (unexplained vaginal bleeding more than 12 months after menstruation has stopped due to the menopause)
  • Consider urgent referral (appointment within two weeks) if they are:
    • aged under 55 with:
      • post-menopausal bleeding

Direct access ultrasound:

  • Consider direct access ultrasound in women:
    • aged 55 and over presenting with unexplained symptoms of vaginal discharge who:
      • are presenting with these symptoms for the first time
      • or
      • have thrombocytosis
      • or
      • report haematuria
  • Consider direct access ultrasound in women:
    • aged 55 and over presenting with visible haematuria and any of the following:
      • low haemoglobin
      • thrombocytosis
      • high blood glucose level

Cervical cancer

Urgent referral:

  • Consider urgent referral (appointment within two weeks) if:
    • the appearance of the woman’s cervix is consistent with cervical cancer 

 Accompanying notes:

  • A smear test is not required before referral, and a previous negative result should not delay referral

Vulval cancer

Urgent referral:

  • Consider urgently referring (appointment within two weeks) women with any of the following unexplained vulval signs or symptoms:
    • a vulval lump
    • ulceration
    • bleeding

Vaginal cancer

Urgent referral:

  • Consider urgent referral (appointment within two weeks) in women with an unexplained palpable mass in or at the entrance to the vagina

Lower gastrointestinal

Colorectal cancer

Urgent referral:

  • Urgently refer (appointment within two weeks) for colorectal cancer in patients:
    • aged 40 and over with:
      • unexplained weight loss and abdominal pain
    • aged 50 and over with:
      • unexplained rectal bleeding
    • aged 60 and over with either:
      • iron deficiency anaemia
      • or
      • alteration in bowel habit
    • with tests that show occult blood in the patient's faeces
  • Consider urgent referral (appointment within 2 weeks) for colorectal cancer in patients:
    • any age with:
      • a rectal or abdominal mass
    • aged under 50 with rectal bleeding and any of the following unexplained signs or symptoms:
      • abdominal pain
      • altered bowel habit
      • weight loss
      • iron deficiency anaemia

Testing for occult blood in faeces

  • In the absence of rectal bleeding, offer testing for occult blood in faeces to patients
    • aged 50 or over with unexplained:
      • abdominal pain
      • or
      • weight loss
    • aged under 60 with either:
      • changes in bowel habit
      • or
      • iron-deficiency anaemia
    • aged 60 and over with:
      • anaemia even in the absence of iron deficiency

Anal cancer

Urgent referral:

  • Consider urgent referral (appointment within two weeks) in patients with either:
    • an unexplained anal mass
    • or
    • unexplained anal ulceration

Guidance

Patient support, safety netting and diagnostic access guidance

  • The following guidance is taken from the NICE 2015 guidance for suspected cancer referral, it includes recommendations on patient support, safety netting and the diagnostic process:
  • Explain to people who are being referred with suspected cancer that they are being referred to a cancer service. Reassure them, as appropriate, that most people referred will not have a diagnosis of cancer, and discuss alternative diagnoses with them
  • When referring a person with suspected cancer to a specialist service, assess their need for continuing support while waiting for their referral appointment. If the person does have additional support needs because of their personal circumstances, inform the specialist (with the person’s agreement)
  • Advise those patients who may not meet immediate referral criteria to re-consult their GP if symptoms persist or progress
  • If direct access for some tests is unavailable in your area, seek an alternative urgent referral pathway
  • You will note that some symptoms from the 2005 NICE guidance for suspected cancer referral have been removed from the guidance update, although there may be no explicit recommendations, refer appropriately if clinical concern persists
  • Give the person information on the possible diagnosis (both benign and malignant) in accordance with their wishes for information (see also the NICE guideline on patient experiences in adult NHS services). Macmillan has more than 500 free booklets available at be.macmillan.org.uk, covering different types of cancer, treatments and side effects. They also offer information and guidance on the day-to- day issues of living with cancer
  • The information given to people with suspected cancer and their families and/or carers should cover, among other issues:
    • how to obtain further information about the type of cancer suspected or help before the specialist appointment
    • what type of tests may be carried out, and what will happen during diagnostic procedures
  • Provide information that is culturally and linguistically appropriate as well as taking in to account the patient’s level of ability. Macmillan’s most commonly requested cancer information is available online to download in a selection of different languages
  • Macmillan’s Online Community is a network of people affected by cancer which anyone can join to get support from others going through a similar experience

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